Posts Tagged ‘Jeffrey Friedman’

It’s 10 O’Clock. Do you Know Where Your Genes Are?

October 5th, 2011

There was a very important story in the New York Times on October 4, 2011 about obesity but you are forgiven if you missed it.  The piece, by Nicholas Wade, tells the story of research on the histories of childbirths on an island in the St. Lawrence River, 50 miles northeast of Quebec. What they found was that the age at which women had her first child fell to 22 years from 26 years from 1799 to 1940. What did you miss? Well, it turns out that the age at which a woman has her first child is a highly heritable trait. And what this finding means is that humans are still evolving.  Statistical tests allowed the researchers to distinguish between the effects of natural selection and changes in cultural practices. Natural Selection Leaves Fresh Footprints on Canadian Island – NYTimes.com

(Readers may recall that the above time-frame is not unlike that employed in The Techno-Physio Revolution, which documented the rise in body weight over 350 years.)

 Not only are humans still evolving but that evolution is occurring faster than many assume.  The DNA sequence can only identify large changes sweeping through a population. But phenotypic or bodily data can provide information on more recent changes.  Wade cites a review article of 14 studies. The lead author, Stephen C. Stearns of Yale,  stated, “We had three general aims: first, to correct the still widespread misconception that natural selection is not operating on contemporary humans; second, to make quantitative predictions about future evolutionary change for specific traits with medical significance; and third, to register firmly a point of general cultural interest that follows directly from our first two aims: We are still evolving, and for some traits we can make short-term predictions about our future evolution.” In this study, the authors found that the descendants of women in the Framingham Heart Study, begun in 1948, are predicted to be on average slightly shorter and stouter, to have lower total cholesterol levels and systolic blood pressure, to have their first child earlier and reach menopause later than they would in the absence of evolution. Colloquium papers: Natural selectio… [Proc Natl Acad Sci U S A. 2010] – PubMed – NCBI 

Jeffrey Friedman noted in the essay I quoted yesterday, “natural selection can be observed in a single generation as nature weeds out the maladapted under changing environmental conditions, leaving the more highly adapted individuals to proliferate. Thus, rapid changes in population characteristics are generally the result of a gene/environmental interaction.” 

What does this have to do with obesity? Well, in discussions about the genetic basis of obesity, skeptics often comment is often that increases in the prevalence of obesity (basically in the last 50 years) cannot be the result of genes because the gene pool or natural selection does not change that rapidly. Yet, evidence to the contrary continues to mount. While no one may be sure just how fast the genome is changing, it is probably inaccurate to say that it cannot change quite rapidly. 

Indeed, an examination of 23 studies reporting data from 14 different countries between 1998 and 2008, indicates a high prevalence of overweight and obesity in pre-school children age 2-5 years, in middle and high income countries, among both well-off and low income segments of populations, in both rural and urban areas and among all ethnic and racial groups represented. Global prevalence of overweight and obesity in… [Anthropol Anz. 2011] – PubMed – NCBI

What’s Wrong with a Little Fat-Bashing?

October 3rd, 2011

So what actually is wrong with fat-bashing? Everyone does it. Isn’t it a good thing to embarrass and ridicule people into healthy behavior? Well, yes. I guess. If it worked. The round of vitriol directed at Chris Christie for his weight is nothing which millions of persons with obesity haven’t experienced in their own families or workplaces or just walking down the street. The problem with telling a person with obesity to eat a salad and take a walk ,like the Washington Post’s Eugene Robinson did, is like telling a person with Parkinson’s disease to just stop shaking or a drug addict to just say no. It ignores the complexity of disease focusing only on the visible end point of a long and complex biological and social process.  

Given the context of the fat-bashing regarding New Jersey Governor Chris Christie, it is useful to revisit Dr. Jeffrey Friedman’s 2003 commentary, “Make War on Obesity, not the Obese.”  

Jeffrey Friedman and Douglas Coleman’s names came up this weekend as possible contenders for the Nobel Prize in Medicine. (They would have my vote if I had a vote) for their work in the discovery of leptin in 1994. Their work  revolutionized obesity research, showing how a hormone produced by fat tissue plays a key role in body weight regulation. 

Friedman’s commentary is still timely and deserves revisiting while obesity, especially extreme or severe obesity, is in the news. I think it remains one of the best scientific explanations of obesity and should give pause to anyone who wants to throw a stone or two.

 His major points are:

 

  1. “There can be no meaningful discussion of obesity until we resist the impulse to assign blame.  Nor can we hold to the simple belief that with willpower alone, one can consciously resist the allure of food and precisely control one’s weight.“

  2. The facts are these “(i) the increasing incidence of obesity in the population is not reflected by a proportionate increase in weight; (ii) the drive to eat is to a large extent hardwired, and differences in weight are genetically determined;  and (iii) obesity can be a good thing depending on the environment in which one (or one’s ancestors) finds oneself.”

  3. The change in weight attributable to any recent changes in diet or a more sedentary life-style is much smaller than the enormous differences in weight, often numbering in the hundreds of pounds, that can be observed among individuals living in today’s world.”

  4. “Twin studies, adoption studies, and studies of familial aggregation confirm a major contribution of genes to the development of obesity. Indeed, the heritability of obesity is equivalent to that of height and exceeds that of many disorders for which a genetic basis is generally accepted. It is worth noting that height has also increased significantly in Western countries in the 20th Century.”

  5. “In general, obesity genes encode the molecular components of the physiologic system that regulates energy balance. This system precisely matches energy intake (food) to energy expenditure to maintain constant energy stores, principally fat. That there must be a system balancing food intake and energy expenditure is suggested by the following analysis. Over the course of a decade, a typical persons consumes approximately 10 million calories, generally with only a modest change in weight. To accomplish this, food intake must precisely match energy output within 0.17% over that decade. This extraordinary level of precision exceeds by several orders of magnitude the ability of nutritionists to count calories and suggests that conscious factors alone are incapable of precisely regulating caloric intake.”

  6.  “Feeding is a complex motivational behavior, meaning that many factors influence the likelihood that the behavior will be initiated. These factors include the unconscious urge to eat that is regulated by leptin and other hormones, the conscious desire to eat less (or more), sensory factors such as smell or taste, emotional state, and others. The greater the weight loss, the greater the hunger and, sooner or later for most dieters, a primal hunger trumps the conscious desire to be thin.”

  7.  The increase in weight is not evenly distributed in the population. “In modern times, some individuals have manifested a much greater increase of BMI than others, strongly suggesting the possibility that in our population (species) there is a subgroup that is genetically susceptible to obesity and a different subgroup that is relatively resistant.”

  8.  “Obesity is not a personal failing. In trying to lose weight, the obese are fighting a difficult battle. It is a battle against biology, a battle that only the intrepid take on and one in which only a few prevail.” A war on obesity, not the obese. [Science. 2003] – PubMed – NCBI.

Obesity Researchers Snag Lasker Prize

September 21st, 2010

September 21, 2010                                                                                                                                

One of the most prestigious awards in medicine has gone to two obesity researchers, Douglas Coleman and Jeffrey Friedman, for their work in discovering the hormone leptin. The discovery of leptin transformed obesity research and this prize recognizes that accomplishment. Congratulations! The Lasker Foundation – 2010 Awards

The War on the Obese – The Ohio Front

October 23rd, 2009

In 2003, a prestigious  researcher, Jeffrey M. Friedman, called for a ‘War on Obesity, not the Obese.” A war on obesity, not the obese. [Science. 2003] – PubMed Result We seem, six years later, not able to make the distinction.

Elsewhere we have addressed various attacks on persons with obesity, rather than obesity itself. Medical experts, it seems, appear particularly unable to tell what is a war on obesity and what is a war on persons with obesity.

A ‘War on Obesity’ includes the same elements that have guided other, successful, approaches to health care problems, whether infectious diseases or chronic conditions. The elements are straight-forward: (1) educate the public and health professionals, (2) focus research on finding both the causes and effective interventions, (3) promote prevention, when possible, (4) intervene and treat those affected, (5) if relevant, strongly combat stigmatization and discrimination, as they are impediments to effectively treating and preventing the disease, and (6) consumer protection to stop the exploitation of worried people and their diversion into unproductive avenues of recourse. With obesity, in general, the federal government has only focused on educating the public and promoting prevention (although we still lack proven prevention strategies). All the other strategies have been not totally, but largely, neglected.

Identifying a “War on the Obese” requires a little work. It requires work because stigmatizing overweight/obese people is so ingrained in our culture. It starts early and does not stop. Shunning, embarrassing, ridiculing and penalizing persons with obesity is so ingrained in our society, we take it for granted. How do we recognize it?

Lets take Dr. Toby Cosgrove, CEO of the Cleveland Clinic, statements about hiring obese persons.

1.       On August 12, 2009, David Leonhardt of the New York Times, wrote, “Cosgrove says if it were up to him, if there weren’t legal issues, he would not only stop hiring smokers. He would also stop hiring obese people. When he mentioned this to me during a recent conversation, I told him many people might consider it unfair. He was unapologetic.”

2.       On September 6, 2009, Dr. Cosgrove was interviewed by Guy Raz on NPR:

RAZ: And you have argued that you would not hire people who are obese. Is that fair?

Dr. COSGROVE: No, I think that that was a quote that was taken out of an hour-and-a-half interview. And what I said was that we are concerned about the obesity problem, not about people who are obese.

3.       September 9, 2009, Cleveland .com carried the story, “Clinics Dr. Delos ‘Toby’ Cosgrove defends remarks about not wanting to hire obese people.” Asked at an obesity summit at the Cleveland Clinic, organized by the clinic’s bariatric surgery program by Walt Lindstrom, founder of the Obesity Law and Advocacy Center in California, if he wished ‘he hadn’t said it.” The Dr. Cosgrove demurred and said his comment was meant “to stimulate discussion on the growing costs of obesity.” He said, “I think a lot of people misunderstood what the point was…I never considered not hiring obese people, but I think we have to do something bold to address the problem.” The article goes on, “Cosgrove opened his remarks at the Obesity Summit by highlighting the Clinics health and wellness initiatives. On the obesity front, the hospital has eliminated fried foods, removed soda and candy from vending machines and subsidized Weight Watchers and fitness programs for its 40,000 employees, he said. “In nine months, we’ve lost 110,000 pounds across the organization, which I think is an amazing tribute to the program.”

4.       September 12, 2009: On a Wall St. Journal Health Blog, Dr. Cosgrove said, “it would be illegal to apply a similar standard (not hiring smokers) to people who are obese, because they’re protected by the Americans with Disabilities Act (ADA). He said, “I can’t decide that I’m not going to hire somebody because they are 400 pounds. We don’t hire smokers and that’s perfectly legal.” According to the blog entry, “Cosgrove questioned that rule, suggesting it could hinder efforts to lower the nation’s obesity rate. Dr. Cosgrove said, “We are protecting people who are overweight rather then giving people a social stigma.”  The blog reports that the Department of Justice said that only morbid obesity can be protected by the ADA but only “if it substantially limits a major life activity in the past or is regarded as substantially limiting.”

5.       On September 13, 2009, Connie Schultz, a Cleveland Plain-Dealer Pulitzer-prize winning columnist for her focus on blue-collar families and economics, wrote, “Apparently, it is now fashionable to bash the obese. For the sake of health care, you understand. Nothing personal.” Quoting Dr. Cosgrove remorse that “We are protecting people who are overweight rather than giving people a social stigma” Schultz states, “What, Oh, he must mean all those obese people bragging about the compliments from strangers, the big, welcoming grins on the faces of fellow airline passengers. Not to mention the parade of size-20 models on fashion runways. Yup, obesity is really popular in America. Who wouldn’t want to be called fat. Punishing obesity compounds the problem.”

6.       September 14, 2009, Dr. Cosgrove apologized to employees of the Cleveland Clinic for any “hurtful” comments, stating, “My objective was to spark discussion about premature causes of death, but some of my comments were hurtful to our community. That was certainly not my intent, and for that I apologize.”

In Cleveland, 70% of adults are over their recommended weight. Obesity is more prevalent among women than men, greater among black adults and higher among older persons than younger ones as well as more prevalent among lower income persons.

The picture of obese persons in Cleveland is intriguing. According to the Center for Health Promotion Research, “Obese and non-obese Clevelanders did not differ in the reporting of adequate fruit and vegetable consumption.” The difference appears to be in physical activity with obese persons reporting less adequate moderate or vigorous physical activity. More than half of all Clevelanders reported not getting adequate weekly amounts of moderate physical activity. BUT, as the report notes, “Clevelanders who were obese were more than twice as likely to report having diabetes (17% vs. 7%) and nearly twice as likely to report having asthma (15% to 8%).”  They also report more hypertension and high cholesterol that non-obese Clevelanders. Therefore, the reports notes, lower levels of physical activity were related to diabetes, hypertension, high cholesterol and heart attacks.

The report goes on to note that obese Clevelanders reported more use of nutrition classes and organized health promotion activities compared to non-obese residents. Fully 75% of obese Clevelanders are trying to lose weight. Of the 76% of Clevelanders who reported seeing a doctor in the past 12 months, only 16% were given advice about their weight! Obese Clevelanders reported using both diet and exercise compared to those who were not obese. And more obese persons used a diet- only approach, “a possible reflection of the mobility issues related to obesity, and the additional need for diet modification.” http://www.case.edu/affil/healthpromotion/Publications/Publications/Steps%20BRFSS%20Data%20Brief%20OBESITY%203.27.08%20FINAL.pdf

Dr. Cosgrove has apologized to his current employees saying he only wanted to talk about premature deaths due to obesity. If he is concerned about premature deaths due to obesity, he might address why does his health plan for employees cover bariatric surgery after a two year waiting period (http://www.clevelandclinic.org/healthplan/plan-cchs-caremanagement.htm#MedBenefitsCoverClarification), one of the longest in the country, and, for which, there is no medical justification?

Even though Dr. Cosgrove has apologized to his employees, does anyone in the hiring process at Cleveland Clinic not understand the boss doesn’t want to see so many fat people on staff? Would you hire an obese Clevelander and take them to meet the boss for the ‘Welcome aboard’ gesture? Not likely.

At the end of the day, there is no evidence that stigmatizing obese persons reverses or resolves the problem. Stigma and discrimination does not work and only increases the sum of human unhappiness. We need new therapies and we need physicians who want to help their patients, and, Dr. Cosgrove, we need positive leadership.